Monday September 16th 2019

Without a home

Nurses offer care, hope to those in need

Tent cities — generally unsanctioned encampments for homeless individuals and families — continue to crop up under freeway passes and bridges and in parks and vacant lots across America, from Los Angeles to Boise, ID, to Charlotte, NC. This phenomenon is perhaps making the homeless population — at least in cities — more visible, and forcing policymakers to seek solutions that will more effectively address the varied needs of this vulnerable population.

Nurses, however, have been on the frontlines of providing health care to homeless adults and children and engaging in larger advocacy efforts for decades. Former American Nurses Association President Barbara Blakeney, MS, RN, FNAP, is one of those nurses. A member of ANA Massachusetts, she was integral to the establishment of the Boston Health Care for the Homeless Program in 1985.

Barbara Blakeney

“Homelessness is a public health issue, a public health emergency,” said Blakeney, who worked in Boston’s public health department for more than 30 years, including as the director of Health Services, Homeless Services Division.  “And it’s hard to live on the streets. People face exposure to extreme cold and heat, and face malnutrition and dehydration.  The streets age you and really beat you up.”

Getting people into housing is a huge step. But there must be accompanying support services, or they will become homeless again, added Blakeney, who now is on the Board of Directors of a Boston-area social services program focusing on homelessness.

According to the National Alliance to End Homelessness, nearly 565,000 people are homeless on any given night in the United States, with those in families accounting for about 36 percent of the total.

Trending data about the homeless, though, can be conflicting. In data pulled together from federal agencies, the Alliance noted that while the number of people living on the streets appears to be on the decline, those staying in shelters or transitional housing appear to be slightly increasing — at least in some measures.

Frankie Manning, MN, RN, reported that officials have declared homelessness in King County and Seattle, WA, a “state of emergency.”  She noted that the Seattle area has a strong network of support services, which has led to an increase of homeless families in particular.

Frankie Manning

“I’m really concerned about the children,” said Manning, a Washington State Nurses Association member who worked within Veterans Affairs for many years. “These children come home from school, and it’s pitch dark at night in these tent communities — except for maybe a pit fire. When they get up in the morning, their feet hit dirt.

“As a society, I feel we should be able to fix homelessness. It’s just so cruel. And I know I’ll continue to work [on this issue] until I can’t move anymore.”

Health care issues, nurse power

Over the years, Blakeney said the causes of homelessness have remained constant and include a lack of affordable housing, economic opportunities and social services; addictions, mental illness or a combination of both; and chaotic home environments. The Alliance reports that families frequently become homeless because of some type of unanticipated financial crisis, such as a health care emergency.

Manning added that any interactions with the criminal justice system make it even more difficult for young people and adults to secure jobs, and in turn, get into stable housing.

In terms of diagnoses, homeless persons have the same health care issues as anyone else, especially as they get older: hypertension, arthritis, type 2 diabetes and heart disease. And particularly for those living on the streets, they also experience many injuries, trauma, infections, the consequences of addictions, and a high rate of mortality for conditions gone untreated, according to Blakeney.

Kathy Lewis

Proper nutrition and tooth loss are common problems, added Kathy Lewis, MPA, BSN, RN, a WSNA member who provides care to many homeless persons at the Pike Market Senior Center in Seattle.

“I see a number of people who are overweight, because they are eating a lot of carbs — really anything to fill their stomachs,” she said. “What they need are wholesome meals.”

And the ability to treat illnesses on the streets is very different than for someone who has a home. For example, nurses and other providers can’t suggest that the patient keep his legs elevated, or take a medication three times a day with food when he might only eat one meal a day at a shelter, Blakeney said.

Manning said there has been a long-standing and effective network of public health nurses providing many services to homeless populations within the Seattle-King County area — even going out to the streets and into tent communities to provide medications to homeless persons and connect them with support resources. Additionally, many nurses, including Manning and Lewis, volunteer through their churches, King County Nurses Association and with the Nurse Reserve Corps, which was originally established to meet people’s needs during natural disasters and other emergencies.

Through the Reserve Corps, nurses routinely hold blood pressure and other screenings, engage in health care teaching, provide much-needed foot care and plan and distribute meals, among other activities.

At a recent King County three-day, health fair for uninsured and underinsured persons, nurses saw more than 4,000 people, the majority of whom were homeless,
Manning said.

Going mobile for children, families

In Los Angeles, nurse practitioners Antoinette Barrett, MSN, RN, CPNP, and Anne Traynor, MN, RN, FNP-BC, provide primary care services, in part, to children and families who live in some type of transitional housing, including temporary government housing, motels or garages, or who double or triple up in the homes of families or friends.

“We see a lot of refugees from Central America, including those who are fleeing violence in their home countries and teenagers who come here on their own,” said Barrett, one of several NPs who provides care via one of two state-of-the-art mobile clinics through the Cedars-Sinai Medical Center COACH for Kids and Families program. Each mobile clinic is staffed by an NP, an RN, a social worker/mental health clinician, an outreach worker and a driver. Running since 1994, the teams provide primary health care and social services at no cost to underserved children and their families around Los Angeles at schools, WIC centers, health fairs, transitional shelters, public housing developments and other localities. No matter where they are parked, they serve the entire community, taking appointments as well as walk-ins.

One major health concern that the NPs see routinely is overweight and obese children, many of whom may also be malnourished, Barrett said. These children often are eating foods “of convenience” and those that can be stretched because of their families’ limited resources and living arrangements. They also are less physically active, because there are no safe places to play.

Three other health care issues that NPs frequently uncover while performing comprehensive histories and physicals on children are asthma, developmental delays and a lack of timely immunizations, including those required to attend school. The NPs then provide both preventive and primary care, if needed, to ensure children don’t end up in the emergency department because a condition went unmanaged.

Michele Rigsby Pauley, Cedars-Sinai Medical Center COACH for Kids and Families. Photo courtesy: Cedars-Sinai Medical Center

Additionally, the social worker on the team does an intake on every family, said Michele Rigsby Pauley, MSN, RN, CPNP, who has been with the program since its inception and is now the program director. Families may need food, housing or mental health services, so the social worker can connect them to local resources.

COACH for Kids and Families also works closely with the Los Angeles Unified School District’s Homeless Education Program, which can help track down children’s previous immunization and other records, particularly in situations where families had to flee their homes quickly because of domestic violence, for example, Rigsby Pauley said. Currently the LAUSD reported 13,794 homeless students within its borders.

Cedars-Sinai also has separate mobile teams to meet the oral health needs and nutrition-focused educational needs of the underserved.

Rigsby Pauley emphasized, “We’re not intended to be the medical home for children and families, so we try to connect them with our clinical partners and other resources within their own communities.” That said, families who include those who are transient, rely on the mobile clinic staff, because NPs and other team members have worked hard to establish rapport and trust with their patients. Each year, the mobile clinic staff engages in 33,000 “encounters” with children and their families.

“What constantly surprises me is that we still are needed to serve children who fall through the cracks,” Traynor added. “There are still so many uninsured and under-insured families, and barriers to care.”

Passion, compassion and collaboration

When Blakeney first started working with the homeless population in the Boston-Long Island, MA-area, clinical care was very spotty and provided by nurse volunteers. But as the infrastructure around shelter services improved, nurses became part of that infrastructure. At its peak in the late 1990s, Blakeney oversaw a paid staff that included NPs, public health nurses, trauma nurses, and psychiatric and addictions nurse specialists.

“I can’t think of a more committed, passionately engaged group of nurses than those who worked and who continue to work with the homeless population,” she said.

And while Massachusetts has a strong program to meet the needs of homeless families, in particular, Blakeney believes an interdisciplinary approach — including experts in health care, housing and skills development — is required in communities around the nation if homelessness is really to be resolved.

“From a health policy perspective, we need to treat addiction as a real illness, as seriously as we treat diabetes, cancer and heart disease, which also means increasing the number of beds for treatment and recovery,” she said.

Lewis believes nurses’ skills in advocacy also can play a vital role in curbing homelessness at the city, state and national level, and encourages RNs to spend time in homeless shelters listening to people’s stories.

“We need to stand with them, because it’s lonely out there,” she said.

Manning also encourages nurses to hold a drive at their workplace, church or other organization to collect much-needed socks, soap, lotion and other personal items.

“But one of the most important things is to smile and speak to someone who is homeless,” she added.

In a final thought, Blakeney added, “Many people feel that once someone becomes homeless, it’s hopeless. It’s a hard road to come back from, but I’ve seen people be successful.”

— Susan Trossman is the senior reporter for The American Nurse.

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